Nursing care of the critically ill patient the trauma bed — a case study

NURSING CARE OF THE CRITICALLY ILLPATIENT

THE TRAUMA BED - A CASE STUDY

STEPHANIE CLARK' S.R.N.. C.C.R.N.Royal Hobart Hospital.' Hobart.

In November 1986,the Intensive Care Unit ofthe Royal Hobart Hospitalpurchased Australia'sfirst, and to date only,Roto Rest KineticTreatment Table orTrauma bed as it iscommonly knovvn. The beditself is of a fairly simpledesign but it is certainlystate of the art in thetreatment of theimmobilised patient.

The human bodydeteriorates vvith lack ofuse and it is obvious thata person must carry outa-~ certain amount ofactivity, belovv vvhichserious degenerationoccurs. Many studies havebeen' carried out on thisminimal activityrequirement, and it hasbeen demonstrated thatnormal, healthy, sleepingsubjects vvill make a grossbody movement every 11.6minutes.(1)(2) Thisobviously essential activityhas been termed theMin i rn u mPh y s'i 0 I0 gi c a IMobility Requirement(M.P.M.R.].

It is vvhen a person isconfined to a bed forvvhatever reason and isunable to meet this

M.P.M.R. that the problemsassociated vvith immobilitybegin to appear. In thelate 60's Dr. Francsis X.Keane, head of Prostheticsand Orthotics at theNational RehabilitationCentre in Ireland, designedthe Roto Rest KineticTreatment Table as ameans of providing theM.P.M.R. for theirnrnobilised patient. Dr.Keane observed that if aperson turned himself ormade a gross bodymovement every 11.6minutes during normalsleep, then he vvould haveto be turned morefrequently by 81 passivemechanical means in orderto achieve the samedegree of protect~cm fromthe com p I i c B t'l' 0 n s 0 fimmobility.

From this carne theconcept of the KineticTreatfTlent Table (K.T.T.], abed that vvould rotateautomatically through apre-set arc, 124"', everythree and a half minutes.In the late 70's, tvvoAmerican doctors modifiedthe K.T.T. and designed afull range of traction tofit the bed. The traumabed vvas born. Any formof traction can be applied

CONFEDERATION JOURNAL Vol. 1 No.118

from cervical, upperextremity, pelvic andlovver extremity. It isextremely light-vveight andeasy to set-up. A uniquefeature of the tractionapparatus is the flexioncable system vvhichabsorbs the moverrtent ofthe bed vvhile it is inrotation and so keeps thelimb in alignment and vvithvveight applied at all tirrtes.

In addition tocontinuous turning, theK.T.T. can be stopped invarious lateral positions toallovv nursing proceduresto be carried out. It shouldbe noted hovvever thatmost nursing functions canbe carried out vvhilst thebed is in rotation. Threemain hatches are locatedon the bed cervical,thoracic and rectalvvhich allovvs access to thepatients entire back.Perhaps the most timeconsurrting aspect of theK.T.T. is actually placingand balancing a patient onthe bed. They must beplaced in the centre ofthe bed and their positionis maintained by closelyfitting body and extrerrtitypacks. Hovvever, once thepatient is positioned andthe bed correctlybalanced, the K.T.T. hasproven to be of enorrrtoushelp to both patients andnursing staff.

EFFECTSTHERAPYSYSTEMS

OF KINETICON BODY

At present, thehazards of irrtmobility hypostatic pneu,-nonia,D.V.T., decubitus _ulcers, toname a fevv are alltreated separately asthey occur, instead oftreating the cause itself.Research has shovvn thatthe K.T.T. has a beneficialeffect on ,-nost bodysystems.

Pulrrtonary -' the constantrotation to 62'~ each sideallovvs for continuouspostural drainage andrrtobiJization of secretions.This improves theventilation/perfusion in thelungs and also helpsprevent hypostaticpneumonia andatelectasis.(3)

Cardiovascular - as eachleg is elevated everythree and a half minutes,it atlovvs for gravitationaldrainage of the veins,thereby helping toprevent venous stasis andreducing the potential fordeep vein thrombosis.Recent studies carried outin the U . S·'. A. - h a v ederrtonstrated this quitegraphic~lIy.(4)

Gastro-intestinal thecontinuous rrtotion of theRoto Rest has been shovvnto stimulate peristalsisand so help reduce theincidence of constipationand i m.p a c ti 0 n inth eirnrrtobilised patient.

Skin - the rrtost obvious

CONFEOERATION JOURNAL Vol. 1 No.119

and perhaps costlycomplication of immobilityis the formation ofdecubitus ulcers. Tissuesbeneath the skin haveshoVV'n regions of ischaemiaafter only tVV'enty minutesof continuous pressureand actual tissuedegeneration has beenshoVV'n to occur in onehour. As pressure pointsare continuo.usly changingVV'hile the patient isautomatically rotating,decubitus ulcer formationis thereby prevented.(5)

Neurological as thepatient has to bedisturbed much less thanVV'ith treatment on aconventional bed, anxietyand sleep deprivation canbe markedly reduced.

Genito-urinary It hasbeen demonstrated thatthe incidence of urinarystasis is reduced, as vvitheach turn, there isimpr.oved gravitationalemptying of each kidneyand better bladderdrainage.(6)

CASE STUDY

Mrs M, a 69 year oldfemale, vvas admitted tothe intensive care unitfolloVV'ing an altercationVV'ith a turning car - MrsM VV'as a pedestrian.Injuries sustained VV'erei- fractured right humerus- fractured tibia and fibulabilaterally

- lacerated supraorbitalregion and occiput- numerous haematomas- aspiration of gastriccontents during transportto hospital

Mrs M vvasresuscitated, intubatedand ventilated and thentransferred to theoperating theatre forinsertion of pins in bothankles for application oftraction.

Arterial blood gasesat this stage shovved anoxygenation of 83mmHgon an Fi02 of 50%.

Over the next tvvelvedays Mrs M's conditionfailed to improve, in· factrespiratory functiondeteriorated. Left lovverlobe collapse vvas detectedtvvo days post admissionand persisted despite tVV'ofibreoptic bronchoscopy's.Efforts to vvean Mrs Mfrom the ventilatorproved fruitless and heroxygenation on an Fi02 ·of45% 50% r~mained

around 55-60mmHg.

Mrs M also presentednursing staff VV'ith anumber of difficult nursingproblems. Her skin vvasvery fragile and therevvas a great risk ofdecubitus ulcer formation.Both leg fractures vvereunstable and vvithcu mbers 0 me tr ac t ionapplied, it vvas difficult tochange her position todeliver good pressure careand physiother-apy. Also,


Mrs M vvas to be thefirst patient in Australiato be placed on theKinetic TreatITlent Table.

Mrs M vvasdulyplaced, positioned and'packed' onto the bed. Atthis stage vve had a minorproblem vvith the pins inboth ankles. They vvere

Before placing Mrs' Mon the bed, I spent aconsiderable aITlount oftiITle vvith her family,explaining the concept ofthe bed, shovvingthemhovv it vvorked andoutlining the benefits. If atall possible it is vvorthvvhileplacing a relative on thebed first to allovv them toexperience it as this canbe reassuring for bothfamily and patient.

Tvvo vveeks follovvingher adITlission it vvasdecided to place Mrs M onthe K.T.T .. We hadhesitated in doing thisbecause, at this stage, notall the intensive care unitstaff had been instructedin the use of the bed.Hovvever, it vvas felt thatMrs M could benefitenormously from theK.T.T. and so I agreed toprovide total back-up andconstant inser-vice for thefirst fevv days, toproITlote staff and patientacceptance of the bed.

vvasandbed

Once Mrs Mcorrectly positionedtraction applied, therequired re-balancing.

too long to allovv propel~

placement of the lovvel~

extremity packs. Hovvever,a large bolt cutter solvedthis problem, As Mrs Mhad traction on both legsit allovved us toexperiment vvith the lovverextremity traction set-up.The traction apparatus isvery versatile and enablesyou to 'build' exactly vvhatyou need, as vve did vvithMrs M.

I had modified theventilator circuit toprevent drag duringrotation, Intravenous lineshad ample length providedthe I.V. poles vverepositioned close to thebed. The indvvellingcat h e t e r vv,a spasse ddovvn through the rectalhatch and the bag vvashung off the base of the

The bed is designedalong the principle of asail-boat - the bed vvith apatient placed on it IS

counter balanced by a'keel' under the bed. It ismost iITlportant toaccurately place thepatient and balance thebed to prevent excessivevvear and tear on themotor and gearmechanism. This can betime consuming, especiallyvvhen traction has beenadded to the bed.

movementM extreme

any manualcaused Mrspain.


bed. A t this stage the bedand the patient vveret-eady for automaticrotation.

Rate: 8T.V.: 650P.E.E.P.:8Fi02: 45%

Mrs M vvascommenced on Kinetictherapy at 6:30pm on aFriday evening. Prior tocom m .e n c e men t , herventilator settings andarterial blood gases vvere:

Mrs M vves naturallyvery apprehensive andtense. It is important tostay by the patient andmaintain eye contactduring the first fevvrotations to allay anyfears. This vve did vvithMrs M.

Watching Mrs Mthrough the first fevv.-otations it vvas evidentthat she experienced painfrom her fractured righthumerus vvhen the bedvvas in the extreme rightlateral position. As thetrauma bed has a variable.rotation pin vvhich allovvsyou to select suitabledegrees of rotation, Ichanged Mrs M to themoderate right setting.This setting rotates thebed the full 62- on theleft ~ide but only rotatesto 40- on the right side.As vveight-bearing onlybegins once you exceed45- tilt, this preventedher putting \Neight on herright arm, thus cornpletelyalleviating her discomfort.

Three days follovvingcommencement of K.T.Mrs M had been \Neaned

7.5535.956.332

9.1

Ph:PC02:P02:HC03:B.E.:

HO\Never, three hoursfollo\Ning commencementof K.T., Mrs M'soxygenation sho\Ned quitea significant improvementvvith a P02 of 95.8 mmHgbeing recorded. This vvassuch a remarkable changein such a short period oftime.

Haemodynamically,Mrs M \Nas stable prior toK.T. vvith a blood pressurerange of 120/70 - 100/60,pulse range of 100-120and a temperatut-e of38.5....· \Nhich had persistedfor the past ten days.Once rotation vvascommenced and Mrs Mhad become accustomedto it, it \Nas noted thatthere \Nere no changes inher haemodynamic status.

T\Nenty-four hoursfollovving commencementof K.T. Mrs M had a clearchest on auscultation andgood air entry in bothbases. Chest x-ray shovvedresolution of left lovverlobe collapse.

I.M.V.mode:


from the ventilator and onan Fio2 of 35% had a P02of 100 mmHg. Mrs M vvasleft on the K.T.T. for afurther thirty-six hoursand then placed on aconventional bed prior toher vvard transfer.

NURSING CONSIDERA TloNS

The nursing staffvvho cared for Mrs Mvvhile she vvas undergoingK.T. found the bed ofenormous value both tothem and the patient. Wefound most nursingprocedures could becarried out vvhilst the bedvvas rotating. The bedvvas usually only stoppedfor lengthy proceduressuch as dressings, bloodsampling etc. Whenvvashing the patient thebed vvas locked in the 62··~

lateral position and thelatches unlocked in turn,the support packsremoved and the exposedarea vvashed, The entireback could be vvashedvvithout moving thepatient. During Kinetictherapy Mrs M's skinimproved remarkably vvithpreviously· reddened areasdisappearing.

Chest physiotherapyvvas easily carried outvvith the bed locked in the62- lateral position andsuctioning vvhilst in thisposition allovved for bette,auctioning of thedependent lung. Limb

physiotherapy vvas givenvvith the bed flat, as sidehatches drop dovvn toallovv you to give fullrange of motion exercisesto all limbs.

Chest x-rays vvereeasy to obtain and did notnecessitate moving thepatient at all. The x-raycassette is slotted into agroove unqerneath thebed and simply moved upor dovvn to the desiredposition. We found thequality of x-ray taken thisvvay to be satisfactory.

Mrs M toleratedkinetic therapy vvell.Traction to both legs vvasmaintained vvithout anyproblems arIsIng. Kinetictherapy enabled her tosleep for long periodsundisturbed, vvhich sheenjoyed. Also, Mrs M novvexperienced little pain asvve did not have tomanually turn her everytvvo . hours somethingvvhich had caused herextreme discomfort dueto the bilateral fracturesand extensive bruising.

Mrs M's fal'T\ily vvereapprehensive at first andneeded a lot ofreassurance. We found vveneeded to take the bedout of rotation for abouttvventy minutes duringtheir visit to allovv thembetter personal contact.

Our first experiencevvith the Trauma bed Ot-


Kinetic Treatment Table, Ifeel, vvas a great success.Acceptance by the staffvvas overvvhelming. Theyfound it very easy to givetotal patient care vvith aminimum of fuss. I alsothink it significantlyreduced Mrs M's stay inthe I.C.U.

As vve place morepatients on the traumabed I believe the researchcarried out in the U.S.A.(7) shovving that you canreduce a patients stay inI.C.U. by 50~b, if treatedvvith kinetic therapy, vvillbe validated.

REFERENCES

1. Johnson et al. In vvhatposition do healthy peoplesleep? ,Journal ofAmerican MedicalAssociation 94, 2059-62.

2. Kleitman, N. Sleep andvvakefulness. Chicago: TheUniversity of ChicagoPress.

3. Schimmel, L. et al. Amechanical method toinfluence pulmonaryperfusion in critically illpatients. ,Journal of CriticalCare Medicine 5, 6.

4. Welch, G.W. (1981).Effects of kinetic bed onvenous filling and emptyingof the lovver extremit~

Presented at the ThirdWorld Congress onIntensive Care and CriticalCare Medicine. Washington

D.C.

5. Leininger, P. et al.(1983). Some nevv factsabout pressure sores.Physicians Update 1\.. 4~

6. Olson, E.V. (1969). Thehazards of immobility. TheAmerican ..Journal ofNursing 67, 4.

7. Adelstein, W. &Watson, P. (1983). Cervicalspinal injuries. ,Journal ofNeurosuraical Nursing 15,- -.2, April.



Documents

Nursing care of the critically ill patient the trauma bed — a case study